Multimodal approach to exploring neighbourhood and transportation dynamics in HIV care in Kenya: protocol

HIV is a major health challenge in Kenya, where prevalence exceeds global averages. Achieving viral suppression depends on consistent adherence to antiretroviral therapy (ART), but individuals in neighbourhoods perceived as disorderly often show low self-efficacy for ART adherence. Despite the importance of neighbourhood dynamics in shaping health behaviours, this area is under-explored in low- and middle-income countries (LMICs), especially regarding transportation barriers. Grounded in Social-Ecological Theory (SET) and the 'Broken Windows' Theory (BWT), SET suggests that health outcomes are influenced by environmental factors, while BWT posits visible signs of neighbourhood disorder, such as neglect and decay, can lead to a decline in healthy behaviours, creating an environment conducive to negative health outcomes. This protocol describes a multimodal qualitative study designed to examine how transportation challenges and perceived neighbourhood dynamics influence HIV care among people living with HIV (PLWH). This intersection of structural barriers, neighbourhood dynamics and HIV outcomes in LMIC settings remains under-researched.

This theory-informed multimodal qualitative study, grounded in a Community-Based Participatory Research framework, integrates individual in-depth interviews (IDIs) and community-based photovoice focus group discussions (FGDs). 20 PLWH participated in IDIs accompanied by a survey with validated scales (~ 10 min) assessing perceived neighbourhood disorder, defined as visible physical and social signs of neglect such as crime, vandalism and deteriorated infrastructure, ART adherence self-efficacy, transportation, access to HIV care and fear of crime. An additional 20 PLWH took part in four photovoice FGD sessions. Photovoice FGD sessions were guided by the SHOWeD questioning technique, a structured reflection method that prompts participants to discuss what they see, what is happening, how it relates to their lives, why it exists and what can be done. In each component, participants were purposively sampled and stratified to ensure approximately equal representation by viral suppression status (10 suppressed, 10 unsuppressed), gender (10 women, 10 men) and age group (10 aged 18-24, 10 older than 24). Interviews and photovoice discussions were transcribed and are being analysed thematically using MAXQDA qualitative analysis software. Participant-generated photographs will be analysed alongside accompanying narratives using an integrated visual and textual coding approach combining inductive and theory-informed deductive analysis. Triangulation across interviews and validated survey measures will be conducted.

This study has received ethical approval from the KNH-UoN Ethics and Research Committee (P635/08/2024) and the Stanford University Institutional Review Board (eProtocol #: 77260). Written informed consent was obtained from all participants. Findings will be disseminated through peer-reviewed publications, conference presentations and a photo exhibition.

This study will contribute to an understudied body of research on how socio-environmental conditions influence HIV care engagement in LMICs. Through the integration of individual-focused in-depth interviews and community-centred photovoice FGD sessions, the study captures both personal perceptions and shared neighbourhood realities. Findings will inform interventions and policy adjustments to improve support for PLHIV in disordered environments.